Provider Demographics
NPI:1013113364
Name:GUPTA, NITIN (MD)
Entity Type:Individual
Prefix:DR
First Name:NITIN
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SUMMIT BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6408
Mailing Address - Country:US
Mailing Address - Phone:770-989-1668
Mailing Address - Fax:678-388-1759
Practice Address - Street 1:980 JOHNSON FY RD NE STE 820
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1608
Practice Address - Country:US
Practice Address - Phone:404-252-9307
Practice Address - Fax:404-252-5839
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22586207R00000X, 207RG0100X
MA249386207RG0100X
GA078939207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02959257Medicaid
MSP01402449OtherRR MEDICARE
GA003203822AMedicaid